CMS Pub. 100-24, ch. 6
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
This chapter identifies key federal components that administer the state buy-in program, as well as resources and procedures for states to address problems with buy-in for specific individuals or transactions.
NOTE: The Centers for Medicare & Medicaid Services (CMS) will only accept electronic communications containing Personally Identifiable Information (PII) that are encrypted or sent through a secure data exchange.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
OFM, Accounting Management Group (AMG), Division of Premium Billing and Collections (DPBC) has overall responsibility for the administration of the state buy-in program including billing, collections, and general program policy.
States may submit inquiries by email to the DPBC resource mailbox at DPBCStateBuy-in@cms.hhs.gov.
DPBC's mailing address is:
CMS, OFM, AMG Division of Premium Billing and Collections Mailstop C3-18-08 7500 Security Blvd. Baltimore, Maryland 21244-1850
DPBC's responsibilities include:
buy-in program.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
OIT, Enterprise Systems Solutions Group (ESSG), Division of Medicare Systems Support (DMSS) has overall responsibility for the data processing of the state buy-in files.
States may submit inquiries by email to the OIT resource mailbox at MepbsEDBSSstaff@cms.hhs.gov.
DMSS' mailing address is:
CMS, OIT, ESSG
Division of Medicare Systems Support
Mailstop N3-17-07
7500 Security Blvd.
Baltimore, MD 21244-1850
DMSS' responsibilities include:
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
OHI, Medicare Ombudsman Group (MOG), Division of Medicare Systems Exceptions and Inquiries (DMSEI) (formerly Division of Ombudsman Exceptions (DOE)) has overall responsibility for the resolution of processing exceptions that states cannot correct through the data exchange process. See section 6.2 for information on how to submit a state buy-in problem resolution inquiry.
States may submit inquiries by email to the DMSEI resource mailbox at statebuy-in@cms.hhs.gov.
DMSEI's mailing address is:
CMS, OHI, MOG
Division of Medicare Systems Exceptions and Inquiries
State Buy-in P.O. Box 11977 Baltimore, MD 21207
Contact the CMS buy-in analyst assigned to your region. Please restrict phone contact to cases that need to be expedited (e.g., congressional and other urgent matters). Please send an email to the DMSEI resource mailbox at statebuy-in@cms.hhs.gov to request a copy of the current state contacts list.
6.1.1.4 - The Center for Medicaid and CHIP Services (CMCS) (Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
CMCS, Children and Adults Health Programs Group (CAHPG), Division of Medicaid Eligibility Policy (DMEP) has overall responsibility for Medicaid eligibility policy.
DMEP's mailing address is:
CMS, CMCS, CAHPG Division of Medicaid Eligibility Policy Mailstop S2-01-16 7500 Security Blvd. Baltimore, MD 21244-1855
CMCS, Financial Management Group (FMG), Division of Financial Operations (DFO) has overall responsibility for the offsets against the Medicaid Grant Award and the Quarterly Expenditure Report for Medical Assistance Payments (Form CMS-64).
DFO's mailing address is:
CMS, CMCS, FMG Division of Financial Operations Mailstop S3-13-15 7500 Security Blvd. Baltimore, MD 21244-1850
6.1.1.5 - The Medicare-Medicaid Coordination Office (MMCO) (Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
MMCO, Program Alignment Group (PAG), works to coordinate components within CMS on issues affecting individuals dually eligible for both Medicare and Medicaid.
States interested in entering into a Part A buy-in agreement with CMS should contact the MMCO resource mailbox at ModernizetheMSPs@cms.hhs.gov.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The responsibilities of the SSA Field Office (FO) or District Office (DO) include accepting Medicare applications, initiating buy-in for certain low-income beneficiaries, and assisting beneficiaries and states agencies with buy-in problems.
The responsibilities of the parallel FO/DO, the lead SSA FO/DO servicing the state Medicaid agency, include liaising with Medicaid buy-in operations personnel, providing technical assistance to other SSA FOs/DOs within the state, and overseeing the resolution of problem cases forwarded to servicing FOs/DOs.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
Responsibilities for the state buy-in program may reside with either the Medicare (OPOLE) or Medicaid (CMCS/MCOG) component of the regional office. Each regional office determines where the program can be most effectively administered and is responsible for liaising with the states, assessing state buy-in operations, and coordinating and implementing procedures within the region (https://www.cms.gov/Medicare/Coding/ICD10/CMS-Regional-Offices).
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The responsibilities of the SSA CO include the establishment and maintenance of the Master Beneficiary Record (MBR) and the Supplemental Security Income Record (SSR), and the daily exchange of new and updated Medicare entitlement and buy-in data with CMS. For more information about the exchange of buy-in data between CMS and SSA, see chapter 2, section 2.3.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The SSA PSCs resolve problems pertaining to Medicare entitlement that impact state buy-in and annotate the MBR for state buy-in transactions that generate errors in automated systems and require manual processing.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The RRB annotates its master eligibility file with state buy-in data processed by CMS for RRB annuitants and assists with the resolution of problems pertaining to Medicare entitlement that may impact state buy-in.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The responsibilities of the state Medicaid agency include:
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
If a state receives a processing error through the data exchange and the problem persists after two attempts by the state to resolve it, the state should send a problem resolution request to DMSEI via email, or, if expedited resolution is required, by phone. For DMSEI's contact information, see section 6.1.1.3.
Only individuals approved by their state Medicaid director may submit inquiries to or communicate with DMSEI about buy-in records. DPBC maintains a list of approved individuals; states may add additional individuals by sending documentation of the state Medicaid director approval to DPBC. For DPBC's contact information, see section 6.1.1.1.
CMS will take all necessary steps to investigate and resolve state problem resolution requests, including working collaboratively with SSA to correct issues that require SSA action to address.
DMSEI can assist states with:
Buy-in updates including accretions, deletions, and change record updates when the state is unable to clear the exception;
Technical assistance and guidance to states on submitting accurate buy-in transactions;
NOTE: CMS will only accept electronic communications containing PII that are encrypted or sent through a secure data exchange. The following information is required to identify and process a case:
To submit a buy-in problem resolution inquiry via email, follow the steps below:
1. Email the DMSEI resource mailbox at statebuy-in@cms.hhs.gov.
2. Indicate "buy-in inquiry - " (e.g., buy-in inquiry - Oregon), in the subject line. The name of the state should be spelled out; please do not abbreviate.
3. Include the information indicated under NOTE above in the email cover.
Please allow 30 business days for processing.
If after 30 business days the problem/issue remains, submit a 'follow-up inquiry' to the DMSEI division director.
To submit a "follow-up inquiry," follow the steps below:
1. Email the DMSEI resource mailbox at statebuy-in@cms.hhs.gov.
2. Indicate "follow-up inquiry" and in the email subject line. The name of the state should be spelled out; please do not abbreviate.
3. Also include "DMSEI Director" in the subject line of the email.
4. Attach a copy of the original email inquiry.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
Once TPS accepts a state accretion request for an individual who is already enrolled in Medicare, CMS will notify SSA to update its records to show the state as the responsible party for premium billing (instead of the individual) effective with the buy-in start date. The federal government generally stops billing the individual upon notification from
CMS. Individuals will receive a refund of any premiums deducted or paid for any month they were enrolled in buy-in.
See SSA POMS HI 00815.039 at https://secure.ssa.gov/poms.nsf/lnx/0600815039.
On rare occasions, federal systems may experience delays in updating SSA’s billing record, resulting in the federal government simultaneously billing both the beneficiary and the state for premiums after the buy-in effective date. States should refer these cases to the DMSEI resource mailbox at statebuy-in@cms.hhs.gov. DMSEI can work with SSA to resolve these issues.
SSA has access to CMS’ third party billing master record through the MBR Health Insurance Query Response (HIQR). The HIQR provides current and prior state buy-in coverage periods and the state agency code(s) for each period. If individuals claims they did not receive a premium refund owed to them, SSA can verify the beneficiary’s buy-in status on the HIQR, correct the beneficiary record in the MBR and issue outstanding refunds to the individual.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
A beneficiary should have only one active Medicare entitlement record, but beneficiaries may have more than one record in rare instances (see chapter 4, section 4.6). If a state detects this error in the billing file, it should not attempt to resolve it since CMS will automatically consolidate the duplicate master records in the next billing month. If automated processes do not resolve issue, CMS may need to take manual action. Submit an inquiry regarding the duplicate billing records to the DMSEI resource mailbox at statebuy-in@cms.hhs.gov. CMS has no time limit on accepting or granting state requests for duplicate billing adjustments. When resolving duplicate billing cases requires changing the individual’s Medicare entitlement data, CMS will refer the case to the federal entity with jurisdiction over the individual’s Medicare entitlement record (i.e., SSA or RRB.)
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
All demographic data in TPS derives from the CMS Enrollment Database (EDB), which originates from SSA. If the name or any other demographic information appears to be incorrect, send a buy-in resolution request to DMSEI. Submit documentation to substantiate a request for a name change or a change to any other demographic field. When the correction requires adjustment of the individual’s Medicare entitlement status, CMS will refer the case to the federal entity with jurisdiction over the individual’s Medicare entitlement (i.e., SSA or RRB.)
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The SSO Report of State Buy-in Problem (Form CMS-1957) facilitates the resolution of problem buy-in cases received by the FO. In most instances, the local FO will learn about a problem through a beneficiary complaint. A sample of the form is in appendix 6.A.
Form CMS-1957 is designed to collect the information needed to resolve the problem case. SSA will route the completed form to the state Medicaid agency, the local eligibility office, or to DMSEI for resolution of the problem.
The FO completes Part 1 (Report of Problem by SSO) and Part 2 (SSI status at FO), if applicable. The FO may need to contact the local eligibility office in order to complete the identification block on the upper right hand side of the form. Subsequent processing of the form will depend upon arrangements negotiated among SSA, CMS ROs, and each state, including whether the local eligibility office or the state Medicaid agency will verify the beneficiary's buy-in status.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The state takes the following actions when it receives Form CMS-1957:
If the state receives an inquiry on an item that requires an adjustment of the accretion or deletion date, for example, the state may explain the problem in Part 4 and request a correction or adjustment.
The parallel FO will forward Form CMS-1957 to DMSEI for necessary action.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
The FO contacts the local eligibility office for assistance in completing the following
items on
Form CMS-1957:
Please leave Part 4 blank.
If Part 3 shows that the beneficiary currently or previously had state buy-in coverage, the FO will route the Form CMS-1957 to DMSEI for resolution.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
States have the responsibility to submit buy-in transactions to CMS for RRB beneficiaries who are enrolled in buy-in. On occasion, the RRB receives complaints from Medicare beneficiaries (through its system of field offices), claiming that they are paying the Part B Medicare premium through deductions from their RRB annuity even though they are enrolled in Part B buy-in.
The RRB Report of State Buy-in Problem (Form RL-380F) helps to facilitate direct communication between the RRB and the state Medicaid agencies to resolve state buy-in problems for RRB Medicare beneficiaries. A sample of the form is included in appendix 6.B. The RRB will neither begin nor terminate Medicare premium deductions from the beneficiary's benefit check unless the state's response shows that the state is liable for the Medicare premiums and the RRB can locate the record on TPS.
The Form RL-380-F provides state Medicaid agencies the individual's correct identifying information (from RRB's Medicare Information Recorded, Transmitted, Edited, and Logged (MIRTEL) Online Inquiry (MOLI)) for the state to investigate the case. When the state Medicaid agency or local eligibility office receives the Form RL-380-F, it should:
If the local RRB field office cannot resolve an issue regarding the beneficiary's Medicare entitlement, the state may contact the RRB in Chicago at (877) 772-5772 or (312) 751-3376.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
Department of Health and Human Services Centers for Medicare & Medicaid Services
Form Approved OMB No. 0008-0065
| SSO REPORT OF STATE BUY-IN PROBLEM To: CMS P.O. Box 11977 Baltimore, Maryland 21207-0977 From: | Name IDENTIFICATION | ||
|---|---|---|---|
| Medicare Beneficiary Identifier | |||
| Railroad Retirement Board (RRB) Number | Sex ☐ M ☐ F | ||
| Welfare ID Number | Social Security Number (BOAN) | ||
| State and County of Residence | |||
| Claimant's Mailing Address | |||
| PART 1 Report of Problem by SSO ☐ A. Part B Claim Denied Carrier Name | ☐ B. Premium being deducted from beneficiary check | ☐ C. Being billed for premiums ☐ D. Individual received Part B Termination Notice | |
| ☐ E. Other (Explain—Give Form numbers if applicable) |
| PART 2 SSI Status at SSO Receiving: Federal SSI Check ☐ Federal Admin. State Supp. ☐ Start Date Stop Date (Attach SSR & HMO Printouts) | ||
|---|---|---|
| Signature of SSO Representative | Title | Date |
| PART 3 Report of Buy-In Status by Welfare Department (Check and Complete Applicable Items) | |
|---|---|
| ACCORDING TO ________ WELFARE OFFICE, THE INDIVIDUAL IDENTIFIED ABOVE. | |
| ☐ 1. Has never been eligible for State buy-in. | |
| ☐ 2. Has been continuously eligible for State buy-in beginning (Mo., Yr.) ________ | |
| ☐ 3. Has been eligible for State buy-in only for months of ____ through ______ (Inclusive) | If eligibility ended because of death, give date of death. |
| PART 4 Information from State's records and/or actions being taken by State | |
|---|---|
| ☐ 1. Individual is shown on State's bill as Code 41 continuing item beginning (Mo., Yr.) ________ | |
| ☐ 2. Individual is shown on State's bill as other code. (Show code) ________ | |
| ☐ 3. State will submit (Show code) ____ in the monthly data exchange (Show month) ______ | |
| Accretion Effective (Mo., Yr.) ________ | Deletion Effective (Mo., Yr.) ________ |
| ☐ 4. Other | ☐ CONTINUED ON REVERSE | |
|---|---|---|
| Dept. of Public Welfare Signature | Title | Date |
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0008-0065. The time required to complete this information collection is estimated to average 17.5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1856.
Form CMS-1957 (04/2018)
Section 1320.6 of title 5 to the U.S. Code authorizes collection of this information. The primary use of this information is to process changes to Hospital Insurance (HI)/Supplemental Medical Insurance (SMI) premium payments by third parties (such as State agencies, or private groups) on behalf of Medicare beneficiaries; for billing third parties; and for enrolling individuals for SMI coverage under State buy-in agreements.
Disclosure of the information may be made to State welfare departments pursuant to agreements with the Department of Health and Human Services for enrollment of welfare recipients for medical insurance under section 1843 of the Social Security Act or a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual.
Furnishing the information on this form including your Social Security Number, is voluntary but failure to do so may result in disapproval of this request.
(Rev. 4, Issued: 08-21-20, Effective: 09-08-20, Implementation: 09-08-20)
UNITED STATES OF AMERICA RAILROAD RETIREMENT BOARD OFFICE OF PROGRAMS/POLICY & SYSTEMS 844 NORTH RUSH STREET CHICAGO, IL 60611-1275 WWW.RRB.GOV
Form Approved OMB No. 3220-0185
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS
TOLL-FREE NUMBER: 1-877-772-8772
| Send reply to: U.S. RAILROAD RETIREMENT BOARD Office of Programs/Policy & Systems 844 North Rush Street Chicago, IL 60611-1275 | RRB Claim Number | |
|---|---|---|
| Medicare Number | ||
| Part A Effective Date | Part B Effective Date | |
| Beneficiary's Own Social Security Number | ||
| Beneficiary's DOB | Sex: Male ☐ Female ☐ | |
| Report of Problem: ☐ Buy-in Accretion Alleged ☐ Buy-in Deletion Alleged ☐ Other: | Social Security Claim Number | |
| Medicaid Number | ||
| Beneficiary's Name | ||
| Beneficiary's Address: | ||
| Signature of RRB Employee | Title | |
| Telephone Number | Date |
Information from State Records or Action Being Taken by State
Read the important notice on the next page.
1. ☐ State has been paying Medicare premium since ___ (Month/Year)
2. ☐ State paid Medicare premium from __ through __ (Month/Year) (Month/Year)
3. ☐ Beneficiary died ___ (Month/Year)
4. ☐ Medicare number under which state paid premium (if different from RRB Medicare claim number)
5. ☐ State will submit a buy-in accretion effective __ in the ____ data exchange with CMS. (Month/Year) (Month/Year)
6. ☐ State will submit a buy-in deletion effective __ in the ____ data exchange with CMS. (Month/Year) (Month/Year)
7. ☐ Buy-in problem case on this beneficiary was submitted to CMS on __ Allow ____ days for resolution. (Month/Year)
8. ☐ Beneficiary never eligible for buy-in.
9. ☐ State has no record of this beneficiary. Beneficiary should contact the following office and file a Medicaid application.
10. ☐ RRB inquiry has been referred to the office listed in item 9 above.
11. ☐ Other:
| Signature of State Representative | Title | |
|---|---|---|
| Printed Name | Telephone Number | Date |
Return this form to the Railroad Retirement Board at the address shown on the first page.
This notice is given under the Paperwork Reduction Act of 1995. Under Section 7(d) of the Railroad Retirement Act (RRA), the Railroad Retirement Board (RRB) is authorized to collect the information requested on this form. The information is needed by the RRB to determine the eligibility of an individual receiving benefits under the RRA for the payment of his or her Medicare medical insurance (Part B) premiums by the State. The information is also used by the RRB to determine if we should stop premium deductions for Medicare medical insurance from the benefits paid to the individual. Your obligation to provide us with this information is required under the law.
We estimate this form takes an average of 10 minutes to complete, including the time for getting the needed data and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-1275.
| Rev # | Issue Date | Subject | Impl Date | CR# |
|---|---|---|---|---|
| R4SPMP | 08/21/2020 | New State Payment of Medicare Premiums, (SPMP) | 09/08/2020 | N/A |